AfyaCheck_mHealth Deck
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Transcript of AfyaCheck_mHealth Deck
A Mobile Health Application for the New MA-CHW Cadre in Tanzania
Initiatives mHealth Consulting GroupCaitlin Gillespie, Lauren Hodsdon, Sarah Jacobson,
Paola Peynetti, Natalie SanfratelloInitiatives Liaison: Rebecca Furth
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Slide deck purpose: Product, impact, why now?1. To present and explain the logic, processes, and prototype of 2. To outline the impact that can have on policy-making, supervision, patient
satisfaction, and MA-CHWs quality care.3. To provide the context and evidence that drive the Tanzanian government the
opportunity to be a leader in the implementation of a comprehensive mHealth tool for frontline health workers.
PRODUCT:
Application
IMPACT: Standardized, Quality Care & Performance
Feedback
WHY NOW?An Opportunity for
Tanzanian leadership in
mHealth
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Identifying the problem: No standardization of mHealth
Current rural health system relies heavily on voluntary Medical Attendant Community Health Workers (MA-CHWs). Government has begun transitioning
to hiring and training MA-CHWs as paid state employees.
Primary Problem:Lack of coordination of MA-CHW performance,
no standardized monitoring or feedback
system.
Secondary Problem:Current mHealth context is diverse & widespread, but
not collaborative or comprehensive
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
A comprehensive mobile health application for MA-CHW home visits
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
New MA-CHW program: A response to a disjointed system
A single, national, cadre of MA-CHWs:● to standardize care, ● ensure sustainability, and ● promote community health
Which includes:● Standardized training● Salary - half minimum gov’t wage● Supplies - transport, health kit, & a job
aid ● 1 MA-CHW per 25 people after
program completes (34)
To establish: ● Appropriate supervision and support
systems, ● Incentive structures, and ● Linkages between health facilities and
health management information systems (HMIS)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Involves MA-CHWs,supervisors, patients, & government
MA-CHW receives patient visit list from local clinic via SMS
MA-CHW takes phone to home visits
MA-CHW registers patient if unregistered
MA-CHW completes necessary modules
eg. ART Adherence Counseling
MA-CHW Uploads data once a week
Supervisor reviews data on patients and MA-CHW performance
Supervisor provides feedback to MA-CHW via SMS or in person
Supervisor uploads data to Tanzanian government monthly
Tanzanian Government uses data to inform policy & practice
START
END
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
The logic behind
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
: A checklist to improve quality of care
Objectives:
● To provide a streamlined checklist for MA-CHW home visits that is: ○ For all components of Tanzanian MA-CHW visit SOP ○ Interactive and collects patient data ○ Able to flag and prioritize patients
● To improve and standardize quality of care to provide comprehensive quality services.
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
will address all components of MA-CHW visit (34)
Reproductive Health & Family
Planning
NutritionHealthy Behaviors
& Disease Prevention
Linkages to the Health System
HIV Counseling
Prototype addresses:ART Counseling
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
The logic behind
ART counseling module prototype
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
ART counseling module prototype: A checklist to improve ART adherence & provide referrals
ART Counseling module: Situated within larger application of all MA-CHW visit components to showcase application use:
○ Reference tool for MA-CHW professional development ○ Ensure data captured is high quality○ Feedback & data analysis for MA-CHW supervisors○ Decision-making support at all levels
● User Guide in Annex
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
: A reference tool for quality care
Promotes decision-making skills and
prioritization of patients according to immediate
need
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Overview of patient case load and needs -
case management
Recording tool of visits completed and needed
to complete
application will ensure high quality data
Through Data Control:● Display and validation logic ● Case management ● Monitoring data
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Sample dashboards: improved quality care
CLINIC SUPERVISOR DASHBOARD NATIONAL STAKEHOLDER DASHBOARD
# Patients Reporting ART Stockouts
% Patient Visits within 30 Days of Previous Visit
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
a. Data: Visit data collected and aggregated in background on■ MA-CHW performance data (supervisor sees MA-CHWs as cases)■ Patient consultation data (confidentiality)
b. Supervision: Quality care and performance feedbackc. Patients:
■ Empowers patients to feel informed and provide feedback ■ Facilitates Confidentiality
: Feedback mechanisms between supervisors,MA-CHWs, & patients
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
● Data collected will support decision-making at different levels of Tanzanian MOHSW:○ National, regional, district health offices and MA-CHW supervisors
● See suggested dashboard in IMPACT section.
The Tanzanian MOHSW● Pharmaceutical Forecasting ● Rural Epidemiology● Demographic and Population Data● Rural Health System Performance
Clinic Levels● MA-CHW Quality of Care● MA-CHW Visit Timelines● Clinic Level Stock Outs● Patients with Access to Health Care● Clinic Referrals
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV The Time Is Now
: Decision-making support at all levels
Scale-up & sustainability of
● Increase Quality of MA-CHW performance and care
● Measurements:○ # of MA-CHWs ○ % of Population
Coverage
● National eHealth Strategy
● Limitations: Cell Coverage and Data Transfer availability
● Strengths: Many mHealth programs already implemented, pilots provide solutions to potential local problems
● CHW job aids are proven effective
● Existing CHW mHealth pilots are effective
● Existing approval of CHWs in communities will bridge any cultural diversities
Parameters Scientific Basis Environmental Context
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
IMPACT:mHealth can bridge delivery gaps
1. CHWs2. DATA 3. SUPERVISION4. PATIENTS5. COSTS
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
● Professional development ● Empowerment and Motivation● Prioritize cases: access data● Health system integration (26)● Standardize care
● M&E of performance● Transparent case mgmt● Communication ● Feedback and reporting
● Data-driven policy & programs● Resource allocation● Data analysis● Adherence to standards
● Confidentiality of information● Lower stigma● SMS decision-making support● Referral systems
DATA
PATIENTS
MA-CHWs (27,36)
SUPERVISORS
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
can bridge service delivery gaps
CHWs: employs best practices to improve motivation & standard of care
Low motivation of CHWs may decrease benefits of investments in CHW
programs (9,27).
Mobile tools help CHWs improve quality of care, efficiency of services,
and capacity of program monitoring (3,27)
mHealth gives CHWs new skills, increases
motivation, and improves community perceptions of CHWs
(12,27,28)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
DATA: im supports data-driven policy-making, program management, & resource allocation“Programmatic efforts to strengthen service delivery focus on improving
adherence to standards and guideline. Mobile tools help CHWs
to improve the quality of care provided, efficiency of services, and capacity for program monitoring” (3).
CHWs use mHealth for collecting field-based health data, receiving
alerts, facilitating health education sessions,
and communication (1)
Review of 25 studies concluded: data
collection is one of the main functions
performed by frontline health
workers (1)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
SUPERVISION: facilitates supervision and feedback mechanismsIn Tanzania, the benefits of
mHealth will be limited without addressing the
current “one-way upward flow of information” (14)
A supervision process to monitor, improve and maintain clinical skill
performance by CHWs is important in program
design and implementation to obtain
health outcomes (34)
mHealth facilitates supervision through regular and prompt
communication across different levels of
providers and easy assessment of the CHW
performance through the web-interface
dashboard (1)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
PATIENTS: informs & empowers patients and increases confidentiality
“Regular access to health information via SMS or mobile-based decision-making support systems
may improve the adherence of the FHWs to treatment
algorithms” (1).
Common barriers to care in Tanzania: long distances to facilities, inappropriate care,
limited decision-making power, low financial
resources, stigma (12)
inSCALE App in Mozambique: phone-based job aid to help
CHWs with consultation steps to assess,
diagnose, treat and refer patients (25)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
COSTS: = A high-impact investment
Financially sustainable mHealth programs need to transfer SMS costs to users (with lower costs negotiated through telecom partners) (15)
Investments in CHWs (1)1) Requirement for achieving UHC2) Results in positive return, as high as 10:13) Scale up has short and long-term savings4) Yields further societal benefits: women
empowerment, reduced patient costs, data collection, additional service delivery
Investments in mHealth (5,6,7,10,19,21,33):1) $100 per phone - Huawei Ascend Y 5112) Less than $5 per month for airtime*3) Dimagi Additional Implementation Package
OptionGrowth Package - $80,000
*Cheka Bombastik Plan on Vodacom: 125 minutes, 1000 SMS, 100MB Data per month
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Why should Tanzania use with the new MA-CHW cadre?
1. Global context: CHWs matter
2. Local context: current Tanzanian mHealth context needs better approach
3. HIV Public health context: MA-CHWs transform HIV/ART care
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Global context: CHWs have great potential with proper support
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
CHWs are indispensable for the SDGs, for UHC, & for access to care in rural areas
“Volunteer CHWs have been with us over many decades and many programs owe their success to these poorly trained and equipped, least supported and unpaid volunteer workforce. They are the unsung heroes of our success whom we have been taking for granted for many years” (23)
- Tanzanian Deputy Minister of Health
“Community health is foundational to attaining many of the SDGs” (30)
115 of the 313 tasks that are essential for HIV prevention and treatment can be performed by CHWs (30)
In developing countries, frontline workers represent the main way most citizens access health services (8,35)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Gaps in CHW training = Gaps in serviceHow mHealth can bridge gaps & improve quality of care
1.
Dynamic, easily customizable platforms
Standardized quality of service delivery + M&E tools
Portable devices: job aids for in-service practice
Mobile platforms for communication & coordination
Mobile toolkit for improved quality of service
Lack of adaptation of training to support local languages (23)
Inconsistent delivery methods and M&E practices(11)
Failure to train where CHWs practice (23)
Lack of coordination with other health providers (25)
Gap in curricula: lack of emphasis on communication skills (23)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Incorporating interactive methods
Repetitive interventions
Case-based training
Blended training (integrating technology)
Emphasizing communication skills
Improve M&E through incorporating consistent CHW feedback and transparent evaluation
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Digital health can improve MA-CHWs in-practice training (2)
Lessons from CHW apps: Feedback is crucial
CommCare Escalating Reminders: SMS reminders and supervisor feedback to CHW to reduce overdue days of patient visits. Improved the timeliness of CHW-patient visits by 86% reduction in number of days an appointment was overdue, decreased from 9.7 days late to 1.4 days. When there was no feedback to the supervisor, CHW performance decreased significantly. (34)
Monitoring of performance and feedback are key in application development
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Local context:mHealth in Tanzania should be collaborative
CHWs are “unsung heroes of our success whom we have been taking for granted for many years”
Tanzanian Deputy MoH
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Four large MNOs, but systems are marginal
and operate below capacity(24)
Mobile Access
64% people have access to a cell phone
31.9 million mobile users(4)
Policy
National eHealth Strategy for 2012-2018 prioritizes professional development for health care workers through
mHealth(17)
mHealth
Lack of collaboration & cohesion
mHealth projects in Tanzania are often
pilots
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Setting the scene: Mobile Access, mHealth, policy
Current mHealth projects in Tanzania are diverse & disjointed, not collaborative or comprehensive.
Examples: ● Mobile for Reproductive Health (m4RH): a national text-message (SMS) based health
communication service in Tanzania and Kenya that provides “simple, accurate and globally relevant information on reproductive health”. Award winning, deployed + created by FHI 360 (15).
● Management Information System (MIS) for control of Neglected Tropical Diseases (NTD): was and mHealth system piloted where village health workers were given mobile phones with web-based software to capture health data (14).
● D-Tree Safer Deliveries in Zanzibar: A collaboration between D-Tree, Tanzania Ministry of Health, JHPIEGO, and Gates Foundation to equip traditional birth attendants and MA-CHWs to register and screen pregnant/postpartum women and newborns (31)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
HIV Public health context: MA-CHWs transform HIV/ART care
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
CHWs play a critical role in community care of PLHIV
The biggest obstacle to scaling up ART care in Sub-Saharan Africa is the lack of qualified human resources for health (10)
MA-CHWs can help fix this problem through task-shifting to community-level care
● CHWs in Zambia are shown to provide adherence counseling of equal quality to clinic counselors, with significantly less loss to follow up rates (29)
● After CHWs in Haiti were trained on HIV care, households in the intervention area increased uptake of ART and attendance at primary health care (18)
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
MA-CHWs can alleviate HIV Burden in Tanzania
HIV prevalence among adults in Tanzania in 2014 was 5.34% which is estimated at 1,499,400 people living with HIV/AIDS (4).
140,000 of PLHIV are children
There are only 0.03 physicians per 1,000 population (4).
Literacy: 70.6 percent of total population (75.9% M, 65.4% female) over the age of 15 can read and write Swahili, English, or Arabic (4).
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
MA-CHWs improve ART adherence in Tanzania● Having low perceived quality of patient-provider interaction and missing a clinic
appointment was associated with poor adherence (32). ● A study of HIV+ mothers found their motivation to take ART decreased after birth and
having prevented MTCT (21). ● Among children, poor adherence was predicted by living with a non-parent caretaker
(22).● Improving adherence counseling in clinic settings may effectively improve adherence to
ART (16). ● Mobile phone text message reminders are recommended to improve ART adherence
(13).
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
The time to lead is now The opportunity is NOW
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
The time to lead is NOWStep up as a regional leader
in mHealth standards, regulation, and systems integration
➔ Quality of close-to-community care over quantity of mHealth projects
➔ Improve the country’s community health information databases.
➔ Take ownership over the nationwide mHealth program
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
The opportunity is NOW
A well-developed, comprehensive smart mHealth project will have significant impact on MA-CHW performance in Tanzania and on health issues like ART adherence and ensure evidence-based, sustainable, data driven programs that empower local communities and make use of the best technology and innovation models.
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions
Contact InformationBoston University School of Public Health
Caitlin Gillespie MPH May ‘16 [email protected] Hodsdon MPH May ‘16 [email protected] Jacobson, MSW MPH May ‘16 [email protected] Paola Peynetti V. MPH Jan ‘17 [email protected] Sanfratello MPH May ‘16 [email protected]
James Wolff (Faculty) MD, MPH [email protected]
Initiatives IncRebecca Furth Ph.D. [email protected]
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References (cont.)
Annex I: User guide
Annex II - Dimagi Costing Tool
Dimagi Costing Tool
If link is inactive, can be found at: https://confluence.dimagi.com/download/attachments/14549044/Dimagi%20-%20CommCare%20-%20TCO_v5-cp.xlsx?version=1&modificationDate=1370536055234&api=v2